Management of Patients Undergoing Endoscopic Procedure - Adult - Ambulatory Consensus Care Guideline

Effective 01/29/2020. Contact [email protected] for previous versions.

Suspected or Confirmed Heart Block: Management of Patients Undergoing Endoscopic Procedure - Adult - Ambulatory Consensus Care Guideline

Note: Active Table of Contents – Click to follow link EXECUTIVE SUMMARY ...... 3 SCOPE ...... 3 METHODOLOGY ...... 4 DEFINITIONS ...... 4 INTRODUCTION...... 5 RECOMMENDATIONS ...... 5 UW HEALTH IMPLEMENTATION ...... 7 APPENDIX A. EVIDENCE GRADING SCHEME(S) ...... 8 APPENDIX B. DIGESTIVE HEALTH CENTER ENDOSCOPY PATIENTS HEART BLOCK ALGORITHM ...... 9 REFERENCES ...... 10

Copyright © 2020 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: [email protected] Vermeulen, [email protected] Last Revised: 01/2020 Effective 01/29/2020. Contact [email protected] for previous versions.

Contact for Content: Name: Deepak Gopal, MD - Gastroenterology Phone Number: (608) 263-7322 Email Address: [email protected]

Contact for Changes: Center for Clinical Knowledge Management Email: [email protected]

Coordinating Team Members: Anne O’Connor, MD- Medicine- Cardiology Joel Johnson, MD- Anesthesiology Jeffrey Lee, MD- Anesthesiology Katherine Le, PharmD- Center for Clinical Knowledge Management (CCKM)

Review Individuals/Bodies: Carin Endres, PharmD- Drug Policy

Committee Approvals/Dates: DHC Executive Committee (03/01/2017) Clinical Knowledge Management (CKM) Council (Last Periodic Review: 01/23/2020)

Executive Summary Guideline Overview This guideline was developed to assist clinicians in determining whether or not to perform an endoscopic procedure for a patient with a newly suspected atrioventricular (AV) block.

Key Practice Recommendations 1. If a patient is diagnosed with a 1st degree AV block or 2nd degree type I AV block and is hemodynamically stable, the endoscopic procedure may be performed. A first-degree heart block is typically not an indication for hospital admission and no specific treatment is generally required.1 A second degree type I AV block usually has a benign cause and treatment is unnecessary in most cases as well.2 (UW Health GRADE Very low quality of evidence, weak/conditional recommendation) 2. If the patient is diagnosed with a 2nd degree type II AV block or 3rd degree AV block, it is recommended to cancel the procedure and treat as clinically indicated. (UW Health GRADE Very low quality of evidence, weak/conditional recommendation) 3. If the AV block occurs during a procedure and resolves spontaneously within seconds or minutes, the physician may consider completing the procedure. (UW Health GRADE Very low quality of evidence, weak/conditional recommendation) 4. If the AV block occurs as a narrow QRS complex or prolonged PR interval with significant decreased in blood pressure or heart rate, the provider may consider giving atropine as it reduces AV block due to hypervagotonia.3,4 (UW Health GRADE Low quality of evidence, weak/conditional recommendation) 5. If AV block occurs more than once after initial resolution, consider aborting the procedure. (UW Health GRADE Very low quality of evidence, strong recommendation) 6. If AV block occurs as multiple P waves in a row or a wide QRS complex, consider aborting the procedure as these are indications that a 2nd degree type II AV block or worse is occurring. (UW Health GRADE Moderate quality of evidence, strong recommendation)

Companion Documents Adult Endoscopy Patients Heart Block Algorithm

Scope Disease/Condition(s): Heart block

Clinical Specialty: Gastroenterology, Cardiology, Anesthesiology

Intended Users: Physicians, Advanced Practice Providers, Nurses

Objective(s): To determine if an endoscopic procedure should be done in a patient with a new AV block who do not have a pacemaker

Target Population: Adult patients who present to the Digestive Health Center or Ambulatory Procedure Center for an endoscopic procedure with a suspected new AV block based off of pre- procedural bedside monitoring.

Interventions and Practices Considered: 1. Cancellation of the procedure 2. Pharmacotherapy for heart block 3

Major Outcomes Considered: 1. None identified

Methodology Methods Used to Collect/Select the Evidence: Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and workgroup members to collect evidence for review. Expert opinion and clinical experience were also considered during discussions of the evidence.

Methods Used to Formulate the Recommendations: The workgroup members agreed to adopt recommendations developed by external organizations and/or arrived at a consensus through discussion of the literature and expert experience. All recommendations endorsed or developed by the guideline workgroup were reviewed and approved by other stakeholders or committees (as appropriate).

Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations: Recommendations developed by external organizations maintained the evidence grade assigned within the original source document and were adopted for use at UW Health.

Internally developed recommendations, or those adopted from external sources without an assigned evidence grade, were evaluated by the guideline workgroup using an algorithm adapted from the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology (see Figure 1 in Appendix A).

Rating Scheme for the Strength of the Evidence/Recommendations: See Appendix A for the rating scheme(s) used within this document.

Recognition of Potential Health Care Disparities: None identified.

Definitions First Degree AV block is a prolongation of the PR interval on an electrocardiogram (ECG). In a first-degree AV block, each P wave is followed by a QRS complex with a PR interval that exceeds 200 milliseconds.5

Second Degree Type I AV block or Mobitz type I AV block occurs when conduction of the atrial impulses to the ventricles is intermittently blocked. It is characterized by a progressive increase in PR interval prior to a blocked non conducted beat/QRS complex. After the dropped QRS, AV conduction recovers resulting in a normal PR interval and a progressive increase in PR interval begins again.1

Second Degree AV block Type II or Mobitz type II AV block is due to intermittent failure of conduction of atrial impulses to the ventricles. It is characterized by fixed PR intervals before and after blocked beats and may be associated with a wide QPRS morphology.6 Advanced second-degree block is the block of two or more consecutive P waves.1

Third Degree AV block happens when there is no conduction of impulses from the atria to the ventricles.5

Introduction Atrioventricular blocks are a disruption in the conduction of the atrial impulse to the heart ventricle. Transient AV block can occur in about 4% of women and 6% of men. This number decreases in the normal older adult population, with Type I second degree AV block observed in about 1% of the population.7 Vagally mediated AV block can occur in otherwise healthy individuals and is generally benign, however it should be differentiated from true type II Mobitz block which requires immediate medical attention.1

Given the vagus nerve’s relationship to the abdomen and parasympathetic nervous system and sedatives’ effect on the respiratory system, it is critical to be attentive to any suspected heart block in a patient undergoing a digestive health procedure. This guideline is meant to aid clinicians in determining how to proceed in a patient undergoing an endoscopic procedure with a newly suspected heart block.

Recommendations Baseline evaluation 1. Patients with a suspected new heart block based off of pre-procedural monitoring should have vital signs checked and be assessed for related symptoms. A brief chart review should also be conducted to check for any previously documented cardiac history (e.g. prior ECGs for comparison) or treatment. 2. Patient should be set up with telemetry for baseline. 3. A 12-lead ECG should be done to assess current heart rhythm in patient.

Diagnosis of AV heart block 1. If patient is diagnosed with a 1st degree AV block or 2nd degree type I AV block and is hemodynamically stable, the endoscopic procedure may be done. A first-degree heart block is typically not an indication for hospital admission and no specific treatment is generally required.1,8 A second degree type I AV block usually has a benign cause and treatment is unnecessary in most cases as well.2 (UW Health GRADE Very low quality of evidence, weak/conditional recommendation) 2. If patient is diagnosed with a 1st degree heart block and with an especially long PR interval (> 300 milliseconds), the endoscopic procedure may be done. (UW Health GRADE Very low quality of evidence, weak/conditional recommendation) 3. If the patient is diagnosed with a 2nd degree type II AV block or 3rd degree AV block, it is recommended to cancel the procedure. a. For 2nd degree type II AV block, it is recommended to consider admission after consultation with cardiology. (UW Health GRADE Very low quality of evidence, strong recommendation) b. For 3rd degree AV block, it is recommended to treat the patient as clinically indicated. (UW Health GRADE Very low quality of evidence, strong recommendation) c. For symptomatic high-degree AV block, provide transcutaneous pacing without delay. Symptoms may include: acute altered mental status, ongoing severe ischemic chest pain, congestive heart failure, hypotension or other signs of shock.9 (UW Health GRADE Very low quality of evidence, strong recommendation)

Intraoperative Heart Block 1. If the AV block occurs during a procedure and resolves spontaneously within seconds or minutes, the physician may consider completing the procedure. (UW Health GRADE Very low quality of evidence, weak/conditional recommendation) 2. If the AV block occurs as a narrow QRS complex or prolonged PR interval with significant decreased in blood pressure or heart rate, the provider may consider giving atropine as it reduces AV block due to hypervagotonia.3,4 Atropine may be given 0.5mg-1mg every 3-5 minutes, up to a maximum of 3 mg total. (UW Health GRADE Low quality of evidence, weak/conditional recommendation) 3. If AV block occurs more than once after initial resolution, consider aborting the procedure. (UW Health GRADE Very low quality of evidence, strong recommendation) 4. If AV block occurs as multiple P waves in a row or a wide QRS complex, consider aborting the procedure as these are indications that a 2nd degree type II AV block or worse is occurring. (UW Health GRADE Moderate quality of evidence, strong recommendation)

Follow-Up 1. Patients with a 1st degree heart block with an especially long PR interval (> 300 milliseconds) or 2nd degree type I AV block should follow-up with primary care provider or cardiologist (if established cardiology patient.) (UW Health GRADE Very low quality of evidence, weak/conditional recommendation) Communication should be made via re: message to primary care staff with documentation on the Problem List. 2. For all patients with newly diagnosed AV block, the physician should consider specifically documenting the block occurred in the patient’s health record. 3. Patients with newly diagnosed AV block who do not use the UW Health system for standard medical care may be provided a copy of his or her ECG for referral/consultation purposes. (UW Health GRADE Very low quality of evidence, weak/conditional recommendation)

UW Health Implementation Potential Benefits: 1. Patient safety

Potential Harms: 1. Patient mortality 2. Overutilization of cardiology consultation services 3. Overutilization of Emergency Department visits

Pertinent UW Health Policies & Procedures None identified.

Patient Resources 1. Health Information- Heart Block 2. Health Information- Heart Rate Problems: Should I Get a Pacemaker? 3. Health Information- Heart Rhythm Problems: Symptoms

Guideline Metrics 1. Number of gastroenterology patients referred to same-day cardiology clinic

Implementation Plan/Clinical Tools 1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines. 2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter. 3. Content and hyperlinks within clinical tools, documents, or Health Link related to the guideline recommendations will be reviewed for consistency and modified as appropriate.

Disclaimer Clinical practice guidelines assist clinicians by providing a framework for the evaluation and treatment of patients. This guideline outlines the preferred approach for most patients. It is not intended to replace a clinician’s judgment or to establish a protocol for all patients. It is understood that some patients will not fit the clinical condition contemplated by a guideline and that a guideline will rarely establish the only appropriate approach to a problem.

Disclosure It is the policy of UW Health that all workgroup members and other persons who may influence content in this guideline disclose all relevant financial relationships with commercial interests. Any disclosure of a relationship listed is not intended to suggest bias in the information presented but rather to provide the reader with information that may be of importance in their evaluation of the information presented.

Appendix A. Evidence Grading Scheme(s)

Figure 1. GRADE Methodology adapted by UW Health

GRADE Ranking of Evidence High We are confident that the effect in the study reflects the actual effect. We are quite confident that the effect in the study is close to the true effect, but Moderate it is also possible it is substantially different. Low The true effect may differ significantly from the estimate.

Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations For or Against Practice The net benefit of the treatment is clear, patient values and Strong circumstances are unlikely to affect the decision.

Recommendation may be conditional upon patient values and Weak/conditional preferences, the resources available, or the setting in which the intervention will be implemented.

Appendix B. Digestive Health Center Endoscopy Patients Heart Block Algorithm Patient Presents for Endoscopic Procedure Additional Details Bedside monitor shows potential NEW heart block

A. RN should obtain vital signs, assess for related symptoms and Brief Chart Review & Medical Screening Exam known history of arrhythmia. Telemetry for baseline A Perform brief chart review for any previously documented cardiac history (i.e., prior EKGs for Obtain 12-lead ECG to assess current heart rhythm comparison) or treatment.

B. In general it is ok to proceed with procedural sedation in st st 1 degree YES patients with 1 degree heart AV block? B block and 2nd degree (type I) and have patients under endoscopic procedure. NO However, if the physician feels otherwise, he/she may consult cardiologist on call. nd 2 degree Perform (type I) YES C. Procedure For symptomatic high-degree AV block?B atrioventricular (AV) block, follow ACLS protocols. Symptoms may include: acute altered mental NO Consider documenting status, ongoing severe ischemic new heart block in note chest pain, congestive heart 3rd degree AV block and adding to Health failure, hypotension, or other 2nd degree (type II) AV Link Problem List. signs of shock. block 2:1 AV block If non‐UW Health patient, give the patient a copy of D. If unsure of rhythm, review case Cancel ProcedureC,D their ECG. and ECG with the on call May warrant inpatient evaluation. Send to Emergency Cardiologists. (This could be done Department or consider direct admission after phone via the UW Access Center if consultation with on call Cardiologist admission is likely). (CARDIOLOGY STAFF WARD (CCU)). Notify Primary Care Intraoperative Heart Block Provider (or Cardiology if Heart block occurs… What to Do established) via re: st …and spontaneously resolves within seconds or message when 1 degree Consider continuing with procedure minutes or resolves with change in patient’s position AV block with long PR nd …as narrow QRS complex or prolonged PR interval Consider giving atropine interval (> 300 msec) or 2 with significant decrease in BP or HR Dosing: Atropine IV 0.5-1 mg, may degree (type 1) AV block. repeat every 3-5 minutes, max of 3mg total

If no resolution after 2nd dose, consider aborting procedure …occurs more than once after initial resolution Consider aborting procedure …multiple P waves in a row or a wide QRS complex Consider aborting procedure

References 1. Cameron P. Textbook of Adult Emergency Medicine Expert Consult - Online and Print. 4th ed. London : Elsevier Health Sciences UK, 2014.; 2014. 2. EA A, Niebauer, J. Cardiology Explained. In: London: Remedica; 2004: https://www.ncbi.nlm.nih.gov/books/NBK2219/. Accessed February 9, 2017. 3. Ferri FF. Ferri's Clinical Advisor 2017 5 Books in 1. : Elsevier Health Sciences, 2016.; 2016. 4. Ganansia MF, Francois TP, Ormezzano X, Pinaud ML, Lepage JY. Atrioventricular Mobitz I block during propofol anesthesia for laparoscopic tubal ligation. Anesth Analg. 1989;69(4):524-525. 5. Crawford MH. Cardiology. 3rd ed. London : Elsevier Health Sciences UK, 2009.; 2009. 6. Ferri FF. Ferri's Clinical Advisor 2017 5 Books in 1. : Elsevier Health Sciences, 2016.; 2016. 7. Saksena S. Electrophysiological Disorders of the Heart Expert Consult. 2nd ed. London : Elsevier Health Sciences, 2011.; 2011. 8. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;64(22):e77-137. 9. Part 7.3: Management of Symptomatic Bradycardia and Tachycardia. Circulation. 2005;112(24 suppl):IV-67.